A Case Report of Complex Clozapine Initiation Despite Contraindications

Introduction Clozapine is well known for its unique efficacy in treatment-resistant schizophrenia and to reduce violent behaviour. Unfortunately, life-threatening adverse reactions including ileus, myocarditis and agranulocytosis can hinder its use. In this context, some clinicians may be reluctant to initiate clozapine in patients who are prone to these adverse drug reactions. Objectives To describe a complex clozapine initiation despite the presence of serious adverse effects and contraindications. The management of these adverse events, using effective multidisciplinary team leadership strategies, will also be described. Methods A case report will be presented. The challenges faced while using clozapine and strategies implemented to pursue the use of this medication will be described. Results A young black man with severe first episode psychosis was admitted to the early intervention outpatient clinic in Québec, Canada. Multiple aggression and critically disorganized behaviour prompted patient transfer to a specialized long-term care unit. Given the severity of the resistant disease and after a shared decision-making process with the family, clozapine was introduced despite ethnic neutropenia (down to 0,2 X 109/L) and idiopathic cerebral lesions. Both gave rise to multiple concerns. A specific hematological surveillance protocol was designed. Facing multiple severe neutropenia episodes, the use of prophylactic granulocyte colony-stimulating factor (300 mcg SC weekly) was added after literature review and a favourable consult of both pharmacist and hematologist. Cardiac enzyme elevation also requested specialized investigation and follow-up. Specialized educators, social workers, and nursing all needed to be deeply involved in the treatment process and team coordination requested strong team building capacities. After 6 months, the patient is now taking clozapine 325 mg daily and his symptomatology has sufficiently reduced to allow hospital leave. The patient is now engaged in his recovery process. Conclusions Using an evidence-based approach, promoting expertise from multiple healthcare professionals, and allowing a substantial amount of time to develop team cohesion were all crucial elements of this success story. Disclosure of Interest None Declared

Introduction: Sexual dysfunction (SD) is a prevalent side effect of antipsychotic drugs (AP), and it impairs patients' quality of life.Because of the distress caused by it, it should be borne in mind when prescribed since it is responsible for treatment nonadherence or discontinuation.SD affects about 45-80% of males and 30-80% of females that take it.In SD, all phases of the sexual response cycle may be compromised.Objectives: This non-systematic review of the literature aims to better understand the antipsychotic-induced SD and its management to better compliance of AP-treated patients without compromising their quality of life.Methods: A semi-structured review on PubMed linking SD as a side effect of AP drugs.Results: All AP drugs can cause SD.It seems related to their mechanism of activity at receptors D2, 5-HT2, α1, H1, and M, which are also involved in sexual function.They do it by diminishing arousal, decreasing libido by blocking motivation and reward system and orgasm indirectly, provoking erectile dysfunction by vasodilatation, and decreasing woman lubrification.Hyperprolactinemia is a significant cause of sexual dysfunctions.Haloperidol, Risperidone, and Amisulpride (prolactin elevating AP) are more likely to cause SD than Olanzapine, Clozapine, Quetiapine, and Aripiprazole (prolactin sparing AP).Although psychotic disorders (Schizophrenia and other psychotic disorders) can impact sexual functioning, according to evidence, there is no denying the role of AP in this issue.Aripiprazole, a D2 partial agonist, has been associated with lower rates of SD and seems to reduce the rates of SD in patients previously treated with other AP.Other AP with the same potential dopamine agonist activity, such as Cariprazine and Brexpiprazole, can probably have the same effect.The management of SD induced by AP drugs should include measuring serum prolactin and modifying risk factors like hypertension, smoking, hyperglycemia, and hypercholesterolemia.In that regard, waiting for spontaneous remission, reducing the dose of the AP prescribed, or switching to Aripiprazole are all viable strategies, if possible.Although the evidence supporting the addition of symptomatic therapies is weak, adding dopaminergic drugs (amantadine, bromocriptine, cabergoline) or drugs with specific effects on sexual functioning (such as phosphodiesterase inhibitors or yohimbine) may be helpful in selected cases.Conclusions: Although all AP drugs can cause sexual dysfunction, it is difficult to determine its true prevalence accurately.AP-induced sexual dysfunction can adversely affect compliance and is one of the factors that must be considered when selecting treatment.In summarizing, Aripiprazole has shown to be the AP with the most favorable profile concerning SD.Cariprazine and Brexpiprazole, being also D2 partial agonists, may cause less SD.

Disclosure of Interest: None
Introduction: Clozapine is well known for its unique efficacy in treatment-resistant schizophrenia and to reduce violent behaviour.Unfortunately, life-threatening adverse reactions including ileus, myocarditis and agranulocytosis can hinder its use.In this context, some clinicians may be reluctant to initiate clozapine in patients who are prone to these adverse drug reactions.
Objectives: To describe a complex clozapine initiation despite the presence of serious adverse effects and contraindications.The management of these adverse events, using effective multidisciplinary team leadership strategies, will also be described.Methods: A case report will be presented.The challenges faced while using clozapine and strategies implemented to pursue the use of this medication will be described.Results: A young black man with severe first episode psychosis was admitted to the early intervention outpatient clinic in Québec, Canada.Multiple aggression and critically disorganized behaviour prompted patient transfer to a specialized long-term care unit.Given the severity of the resistant disease and after a shared decision-making process with the family, clozapine was introduced despite ethnic neutropenia (down to 0,2 X 10 9 /L) and idiopathic cerebral lesions.Both gave rise to multiple concerns.A specific hematological surveillance protocol was designed.Facing multiple severe neutropenia episodes, the use of prophylactic granulocyte colony-stimulating factor (300 mcg SC weekly) was added after literature review and a favourable consult of both pharmacist and hematologist.Cardiac enzyme elevation also requested specialized investigation and follow-up.Specialized educators, social workers, and nursing all needed to be deeply involved in the treatment process and team coordination requested strong team building capacities.After 6 months, the patient is now taking clozapine 325 mg daily and his symptomatology has sufficiently reduced to allow hospital leave.The patient is now engaged in his recovery process.Conclusions: Using an evidence-based approach, promoting expertise from multiple healthcare professionals, and allowing a substantial amount of time to develop team cohesion were all crucial elements of this success story.

EPV0947
Post Cerebrovascular Stroke Catatonic Psychosis: A Case Report H. Hasan1 *, M. Abdo2 and S. Rabei 1 Introduction: Catatonia due to cerebrovascular stroke is a rare condition that needs further observation and research.Objectives: To review the opinions of psychotic disorders experts worldwide as to this issue based on evidence and clinical experience and to consider strategies for future investigations.Methods: This case shows a 64 years old female who suddenly developed wish for isolation, followed 10 days later by discontinuity of ideas, hallucinatory behavior and food refusal.She had verbal and physical aggression due to a fixed belief that family members are conspiring somehow to harm her.Results: On examination she was mute with waxy flexibility and negativism.Extensor plantar reflex was evident.MRI Brain showed small vessel disease and right basal ganglia acute ischemic infarction.On IV midazolam 7.5 mg, patient's mutism, negativism and waxy flexibility improved.Lower limb Venous Duplex revealed acute right popliteal and left soleal veins thrombosis.CT angiography showed Bilateral pulmonary embolism with no pulmonary infarction.D dimer was positive.Conclusions: Early diagnosis and intervention improves outcome if psychiatric teams gives attention and has enough awareness with warning symptoms and prompt necessary interventions.

EPV0948
A complex polymorphous psychosis or a cycloid psychosis with a different onset?
Introduction: Acute and transitory psychotic disorders comprise a polymorphous picture such as Leonhard's cycloid psychoses, which alternate episodes of affective symptoms such as psychosis between two poles (anguish/happiness, incoherence/stupor, or akinesia/ hyperkinesia).Objectives: To describe a case report of a 20-year-old man, in outpatient psychiatric follow-up, after debuting at age 18 with a severe depressive episode of endogenomorphic characteristics without psychotic symptoms, with subsequent complete remission.Two years after clinical stability, he required prolonged hospitalization due to polymorphous psychotic syndrome of abrupt onset in a context of previous continuous use of cannabis and cocaine.Suspicion towards parents, bizarre behaviors, rushing desires, unmotivated laughter, fixed gaze, bewilderment, anguish with a feeling of imminent death, alternates with euphoria and senseless purchases.Methods: We present the case report of this patient with a mental examination of conscious, scattered attention with marked distractibility, confusion and experiences of strangeness, memory gaps, subjective sensation of well-being with tachypsychia, which fluctuates with thymic oscillations and alternates with episodes of marked indefinite anguish, intense anxiety with delusional fear of the death of him or his family.Little systematized ideas of reference and prejudice based on intuitions or delusional occurrences in their environment.Megalomaniac and religious-messianic ideation.No sensory perception disturbances.Disintegrated course of thought, with frequent illogical associations, ambivalence of thought, affectivity and psychomotricity.Motor restlessness and behavioral disorganization.Global insomnia.Judgment of reality and superior functions diminished.No auto/heteroaggressiveness. Results: Various psychoactive drugs were tested for two months, obtaining a response only with valproic acid 1500mg, pregabalin 450mg and olanzapine 15mg, presenting slow improvement in a situation of absence of consumption, with a predominance of symptomatic polymorphism, decreasing fluctuation between episodes of expansiveness and psychotic anguish, remitting disorganization and motility alterations, persisting poor awareness of the disease and cognitive complaints.He was referred for follow-up at the mental health center where his gradual recovery continued.A differential diagnosis of polymorphous psychosis is proposed, compatible with a cycloid psychosis of the anxiety-happiness type with marked affective symptoms, precipitated by substance use.Conclusions: Cycloid anxiety-happiness psychosis stands out for intense and fluctuating anxiety, oscillating with feelings of